Dietary Blueberry and Soluble Fiber Supplementation Reduces Risk of Gestational Diabetes in Women with Obesity in a Randomized Controlled Trial.

BACKGROUND: Gestational diabetes mellitus (GDM) is a growing public health concern and maternal obesity and poor dietary intakes could be implicated. Dietary polyphenols and fiber mitigate the risk of diabetes and its complications, but little is known about their efficacy in preventing GDM. OBJECTIVES: We examined the effects of whole blueberry and soluble fiber supplementation on primary outcomes of cardiometabolic profiles in women at high risk of developing GDM. METHODS: Women (n = 34; mean ± SD age: 27 ± 5 y; BMI: 35.5 ± 4.0 kg/m2; previous history of GDM ∼56%; Hispanic ∼79%) were recruited in early pregnancy (<20 weeks of gestation) and randomly assigned to 1 of the following 2 groups for 18 wk: intervention (280 g whole blueberries and 12 g soluble fiber per day) and standard prenatal care (control). Both groups received nutrition education and maintained 24-h food recalls throughout the study. Data on anthropometrics, blood pressure, and blood samples for biochemical analyses were collected at baseline (<20 weeks), midpoint (24-28 weeks), and end (32-36 weeks) of gestation. Diagnosis of GDM was based on a 2-step glucose challenge test (GCT). Data were analyzed using a mixed-model ANOVA. RESULTS: Maternal weight gain was significantly lower in the dietary intervention than in the control group at the end of the trial (mean ± SD: 6.8 ± 3.2 kg compared with 12.0 ± 4.1 kg, P = 0.001). C-reactive protein was also lower in the intervention than in the control group (baseline: 6.1 ± 4.0 compared with 6.8 ± 7.2 mg/L; midpoint: 6.1 ± 3.7 compared with 7.5 ± 7.3 mg/L; end: 5.5 ± 2.2 compared with 9.5 ± 6.6 mg/L, respectively, P = 0.002). Blood glucose based on GCT was lower in the intervention than in the control (100 ± 33 mg/dL compared with 131 ± 40 mg/dL, P < 0.05). Conventional lipids (total, LDL, and HDL cholesterol and triglycerides) did not differ between groups over time. No differences were noted in infant birth weight. CONCLUSIONS: Whole blueberry and soluble fiber supplementation may prevent excess gestational weight gain and improve glycemic control and inflammation in women with obesity.This trial was registered at clinicaltrials.gov as NCT03467503.

"New or not-so-new" labor management practices and cesarean delivery for arrest of progress.

BACKGROUND: Because nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours. OBJECTIVE: To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation. MATERIALS AND METHODS: Between January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions. RESULTS: A total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation. CONCLUSION: Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.

A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor.

BACKGROUND: It has been suggested that the development of maternal fever during epidural analgesia could be due to intrapartum infection. We investigated whether antibiotic prophylaxis before epidural placement decreases the rate of epidural-related fever. METHODS: In this double-blind, placebo-controlled trial, 400 healthy nulliparous women requesting epidural analgesia were randomly assigned to receive either cefoxitin 2 g or placebo immediately preceding initiation of epidural labor analgesia. Maternal tympanic temperature was measured hourly, and intrapartum fever was defined as a maternal temperature of ≥38°C. Neonates born to women with fever were evaluated for possible sepsis, and available placentas were evaluated for the presence of neutrophilic inflammation. The primary outcome was maternal fever during epidural analgesia. RESULTS: Thirty-eight percent of women in the cefoxitin group and 40% of women in the placebo group developed fever (P = 0.68). The risk difference (95% confidence interval) for fever ≥38°C during labor (antibiotic versus placebo) was -2.0% (-11.5 to 7.5), and for fever >39°C during labor was -1.5% (-4.7 to 1.7). Approximately half of each study group had placental neutrophilic inflammation, but administration of cefoxitin had no significant effect on any grade of neutrophilic inflammation. Fever developed significantly more often in the women with placental neutrophilic inflammation compared with those without such inflammation (73/158 vs 33/144, P < 0.001; risk difference 23% [95% confidence interval, 13.0-34.0]). There were no significant differences in any neonatal outcomes between the antibiotic and placebo study groups. Sepsis was not diagnosed in any of the infants. There were no neonatal deaths. CONCLUSION: Fever during labor epidural analgesia is associated with placental inflammation, but fever and placental inflammation were not reduced with antibiotic prophylaxis. This finding suggests that infection is unlikely to be the cause in its development.

Effects of an Eating Pattern Including Colorful Fruits and Vegetables on Management of Gestational Diabetes: A Randomized Controlled Trial.

Gestational diabetes mellitus (GDM), defined as abnormal glucose tolerance that presents during the second and third trimesters of pregnancy, is a growing issue in the United States and worldwide. If left untreated or poorly controlled, GDM can result in numerous consequences for both the mother and the fetus; thus, it is imperative that different avenues of management for GDM be explored. There is a paucity of studies that examine how lifestyle changes, including dietary and physical activity, affect management of GDM. We examined how counseling on lifestyle changes can affect cardiometabolic risks in women with GDM. We conducted a 12-week randomized controlled trial based on behavioral counseling in which women with GDM (N = 38) were randomized into either a nutrition education (control) (N = 18) group or nutrition intervention (N = 20) group. The nutrition education group were given dietary counseling regarding healthy dietary choices based on USDA guidelines, while the nutrition intervention group were instructed to consume a total of one cup of whole berries and one cup of leafy vegetables daily along with performing postprandial exercise (walking). Blood samples, anthropometric measures, and dietary and physical activity data, recorded in daily food and activity logs, were collected at baseline and at the end of the study and compared between the two groups. Dietary counseling on supplementation with whole berries and leafy vegetables resulted in increased fiber intake, increased antioxidant intake and total serum antioxidant capacity, improved random blood glucose, decreased serum IL-6, and improved HDL cholesterol versus the control group (all p < 0.05). These results highlight that whole berry and leafy vegetable supplementation-based dietary counseling can improve the metabolic pathways involved in gestational diabetes pathogenesis and prognosis. These functional foods must be recommended in the management of pregnancies affected by GDM.

Endothelial microparticles and the antiangiogenic state in preeclampsia and the postpartum period.

OBJECTIVE: We sought to determine if endothelial microparticles (EMPs), markers of endothelial damage, are associated with soluble fms-like tyrosine kinase 1 (sFlt1), soluble endoglin, and placental growth factor (PlGF) in women with preeclampsia. STUDY DESIGN: A prospective cohort study was conducted on 20 preeclamptic women and 20 controls. EMPs by flow cytometry, sFlt1, soluble endoglin, and PlGF were measured at time of enrollment, 48-hours postpartum, and 1-week postpartum. RESULTS: Preeclamptic CD31(+)/42(-), CD62E(+), and CD105(+) EMP levels were significantly elevated in preeclamptics vs controls at time of enrollment. The sFlt1:PlGF ratio was correlated with CD31(+)/42(-) and CD105(+) EMPs (r = 0.69 and r = 0.51, respectively) in preeclampsia. Levels of CD31(+)/42(-) EMPs remained elevated 1-week postpartum (P = .026). CONCLUSION: EMPs are elevated in preeclampsia. The correlation of EMPs and the sFlt1:PlGF ratio suggests that antiangiogenesis is related to apoptosis of the endothelia. Endothelial damage persists 1 week after delivery.

A randomized trial of birthing with and without stirrups.

OBJECTIVE: The objective of the study was to determine whether bed delivery without stirrups reduces the incidence of perineal lacerations compared with delivery in stirrups. STUDY DESIGN: In this randomized trial, we compared bed delivery without stirrups with delivery in stirrups in nulliparous women. The primary outcome was any perineal laceration (first through fourth degree). RESULTS: One hundred eight women were randomized to delivery without stirrups and 106 to stirrups. A total of 82 women randomized to no stirrups (76%) sustained perineal lacerations compared with 83 in women allocated to stirrups (78%) (P = .8). There was no significant difference in the severity of lacerations or in obstetric outcomes such as prolonged second stage of labor, forceps delivery, or cesarean birth. Similarly, infant outcomes were unaffected. CONCLUSION: Our results do not incriminate stirrups as a cause of perineal lacerations. Alternatively, our findings of no difference in perineal lacerations suggest that delivering in bed without stirrups confers no advantages or disadvantages.

Defining uterine tachysystole: how much is too much?

OBJECTIVE: We sought to determine if uterine tachysystole, ≥ 6 contractions per 10 minutes, within the first 4 hours of labor induction, is associated with adverse infant outcomes. STUDY DESIGN: This was a prospective cohort study of 584 women ≥ 37 weeks' gestation undergoing induction of labor with 100 µg of oral misoprostol. Fetal heart rate tracings were analyzed for contractions per 10 minutes during the initial 4 hours after misoprostol administration. Patients were analyzed based on the maximum number of contractions per 10 minutes. Infant condition at birth was assessed using the fetal vulnerability composite. RESULTS: Adverse infant outcomes showed no association with increasing number of contractions per 10 minutes. Six or more contractions in 10 minutes were significantly associated with fetal heart rate decelerations (P ≤ .001). Analysis was performed using the maximum number of contractions per 30 minutes with similar results. CONCLUSION: Uterine tachysystole, as currently defined, when occurring remote from delivery is not associated with adverse infant outcomes.

Calculated blood loss in severe obstetric hemorrhage and its relation to body mass index.

OBJECTIVE: To evaluate total calculated blood loss at the time of severe obstetric hemorrhage. STUDY DESIGN: This is a prospective observational study of women with obstetric hemorrhage. Women who received a blood transfusion for hypovolemia and those in which a body mass index (BMI) could be calculated were included. Total blood volume lost was calculated. Blood loss was analyzed in relation to maternal size as reflected in the BMI. RESULTS: Fourteen hundred forty-three women meeting inclusion criteria delivered at our hospital between March 2002 and June 2006. The median calculated volume of blood lost was 3529 mL, and 93% of women sustained losses ≥3000 mL. The blood loss sufficient to provoke signs and symptoms of hypovolemia was proportional to the woman's BMI. CONCLUSION: Women who develop hypovolemia during childbirth have suffered very large losses of blood, and infusion of blood products is required to restore circulation and prevent further morbidity.

Neonatal effects of magnesium sulfate given to the mother.

OBJECTIVE: Magnesium historically has been used for treatment and/or prevention of eclampsia or preterm labor. More recently, antepartum magnesium sulfate has been suggested for prevention of cerebral palsy in preterm infants. Although adverse effects and toxicity of magnesium in pregnant women are well known, the fetal-neonatal effects of magnesium are less clear. The objective of this study was to evaluate the effects of magnesium on the newborn infant. STUDY DESIGN: This is a retrospective cohort analysis of women who received antepartum magnesium sulfate for prevention or treatment of eclampsia. Magnesium sulfate was given intravenously beginning with a 6-g dose, followed by 2- to 3-g/h infusion. Newborn hypotonia was diagnosed if an infant exhibited less than normal tone/activity upon admission to the nursery. RESULTS: Between January 2000 and February 2009, a total of 6654 women with preeclampsia were treated with intravenous magnesium sulfate as described; 88 (6%) of the infants were diagnosed with hypotonia. Lower 1-minute and 5-minute Apgar scores, intubation in the delivery room, admission to special care nursery, and hypotonia were all significantly increased as maternal serum magnesium concentrations increased before birth. CONCLUSION: Several neonatal complications are significantly related to increasing concentrations of magnesium in the maternal circulation.

An analysis of second-stage labor beyond 3 hours in nulliparous women.

OBJECTIVE: To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional. STUDY DESIGN: Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database. RESULTS: Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours. CONCLUSION: Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.

Socioeconomic impacts on the intergenerational associations of preterm birth.

BACKGROUND: The impact of socioeconomic status on intergenerational associations of preterm birth (PTB) is poorly understood. OBJECTIVE: To estimate the socioeconomic status of intergenerational impact of PTB transmission. STUDY DESIGN: This retrospective cohort study included all eligible singleton female infants born in Nebraska from 1995 to 2005 (n = 6631) and followed up from 2009 to 2019. Mothers' first singleton infants born 2009-2019 were linked to the mothers and included in the description and generalized estimating equations. RESULTS: Mothers born PTB were 37% more likely to have a PTB infant after controlling for maternal and grandmother's prenatal care adequacy, maternal residential poverty, pre-pregnancy diabetes, hypertension, C-section, and infants' gender. In poor neighborhoods, the adjusted preterm odds ratio of former born preterm mothers (compared with mother not born PTB) was 1.56 (95% confidence interval (CI): 1.02, 2.38). Moreover, moving from a poor neighborhood to a relatively well-off neighborhood was a protective factor for PTB with an adjusted odds ratio of 0.47 (95% CI: 0.23, 0.95). CONCLUSIONS: Mothers born preterm were at increased risk of having PTB infants, especially in poor areas. Maternal upward social mobility was a protective factor for PTB recurrence.

Utility of the cerebroplacental ratio (CPR) in marijuana exposed growth restricted fetuses.

OBJECTIVE: Fetal growth restriction (FGR) is associated with an increased risk of adverse perinatal outcomes. The cerebroplacental ratio (CPR) represents the interaction of alterations in blood flow to the fetal brain and placenta. CPR has been utilized as a superior reflection of fetal hypoxia/acidemia and therefore a better predictor of fetal morbidity. We sought to determine the role of the CPR as an adjunctive tool to identify fetuses at increased risk of adverse perinatal outcomes in a study population of marijuana (MJ) exposed FGR fetuses. METHODS: This was a retrospective cohort study of high-risk singleton pregnancies over a 4-year period. Self-identified daily MJ users with FGR fetuses in the 3rd trimester were isolated. Fetal biometry, amniotic fluid indices, and CPRs were calculated. A CPR <1 was considered abnormal. FGR fetuses with normal and abnormal CPRs were then compared. RESULTS: 26/192 (13.5%) of MJ exposed fetuses were diagnosed with FGR in the 3rd trimester. 12/26 (46%) had an abnormal CPR and 14 had a normal CPR (mean CPR 0.60 vs 1.57, p = .0001). The mean EFW percentile was lower in the abnormal CPR group in comparison to the group with normal CPR (3.33 vs 7.64, p = .0001). Both groups showed evidence of brain sparing with an overall mean head circumference of 17.55 in comparison to a mean abdominal circumference of 5.63. A CPR <1 was associated with more severe FGR, oligohydramnios, and abnormal UA Doppler studies. CONCLUSIONS: Approximately half of the MJ exposed FGR fetuses had an abnormal CPR. In this subset of patients, >90% had severe FGR, a higher proportion had absence/reversal of end diastolic flow in the UA, and a higher proportion had oligohydramnios. This demonstrates that an abnormal CPR identifies a group of FGR fetuses at a greater risk of adverse perinatal outcomes.

A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy.

BACKGROUND: Research suggests that fetal exposure to magnesium sulfate before preterm birth might reduce the risk of cerebral palsy. METHODS: In this multicenter, placebo-controlled, double-blind trial, we randomly assigned women at imminent risk for delivery between 24 and 31 weeks of gestation to receive magnesium sulfate, administered intravenously as a 6-g bolus followed by a constant infusion of 2 g per hour, or matching placebo. The primary outcome was the composite of stillbirth or infant death by 1 year of corrected age or moderate or severe cerebral palsy at or beyond 2 years of corrected age. RESULTS: A total of 2241 women underwent randomization. The baseline characteristics were similar in the two groups. Follow-up was achieved for 95.6% of the children. The rate of the primary outcome was not significantly different in the magnesium sulfate group and the placebo group (11.3% and 11.7%, respectively; relative risk, 0.97; 95% confidence interval [CI], 0.77 to 1.23). However, in a prespecified secondary analysis, moderate or severe cerebral palsy occurred significantly less frequently in the magnesium sulfate group (1.9% vs. 3.5%; relative risk, 0.55; 95% CI, 0.32 to 0.95). The risk of death did not differ significantly between the groups (9.5% vs. 8.5%; relative risk, 1.12; 95% CI, 0.85 to 1.47). No woman had a life-threatening event. CONCLUSIONS: Fetal exposure to magnesium sulfate before anticipated early preterm delivery did not reduce the combined risk of moderate or severe cerebral palsy or death, although the rate of cerebral palsy was reduced among survivors. (ClinicalTrials.gov number, NCT00014989.)

A dose-finding study of oral misoprostol for labor augmentation.

OBJECTIVE: We designed a dose-finding trial of oral misoprostol administered for labor augmentation. STUDY DESIGN: Healthy, nulliparous women in active labor and diagnosed with arrest of dilation were enrolled in cohorts of 10 at a time. Five regimens were studied: (1) 25 µg every 4 hours, (2) 50 µg every 4 hours, (3) 100 µg every 4 hours, (4) 50 µg every 2 hours, and (5) 75 µg every 4 hours. RESULTS: A total of 46 women were enrolled. Baseline uterine activity approximately doubled with 4 of the regimens and tripled with the highest dosage regimen (100 µg) (P < .001). The 100-µg regimen was truncated due to excessive uterine hyperstimulation (40%). CONCLUSION: An oral dose of 75 µg of misoprostol given at a 4-hour interval for a maximum of 2 doses is the highest tolerated dose. Randomized, controlled trials will be required before a regimen is employed routinely.

Dietary Blueberry and Soluble Fiber Improve Serum Antioxidant and Adipokine Biomarkers and Lipid Peroxidation in Pregnant Women with Obesity and at Risk for Gestational Diabetes.

Pregnancies affected by obesity are at high risk for developing metabolic complications with oxidative stress and adipocyte dysfunction contributing to the underlying pathologies. Few studies have examined the role of dietary interventions, especially those involving antioxidants including polyphenolic flavonoids found in fruits and vegetables on these pathologies in high-risk pregnant women. We conducted an 18 gestation-week randomized controlled trial to examine the effects of a dietary intervention comprising of whole blueberries and soluble fiber vs. control (standard prenatal care) on biomarkers of oxidative stress/antioxidant status and adipocyte and hormonal functions in pregnant women with obesity (n = 34). Serum samples were collected at baseline (<20 gestation weeks) and at the end of the study period (32-26 gestation weeks). Study findings showed maternal serum glutathione and antioxidant capacity to be significantly increased, and malondialdehyde to be decreased in the dietary intervention vs. control group (all p < 0.05). Among the adipokine biomarkers, serum plasminogen activator inhibitor-1 and visfatin, as biomarkers of adipocyte dysfunction and insulin resistance, were also decreased following dietary intervention (all p < 0.05). These findings support the need for supplementing maternal diets with berries and fiber to improve oxidative stress and risks of metabolic complications during pregnancy.

Effect of intrauterine marijuana exposure on fetal growth patterns and placental vascular resistance.

OBJECTIVE: The recent legalization of marijuana has increased overall use, including in pregnancy. Studies have previously associated marijuana use with adverse fetal neurodevelopmental outcomes. We sought to compare fetal sonographic growth parameters and placental perfusion, as measured by umbilical artery Dopplers, in women using daily marijuana versus nonusers. METHODS: A retrospective cohort study capturing self - identified pregnant daily marijuana users with gestational aged matched controls was performed. We compared maternal demographics, fetal biometry, nuchal translucency, and umbilical artery Dopplers in marijuana users versus controls. Intrauterine growth restriction was defined as an estimated fetal weight <10th %. RESULTS: In 55 first trimester ultrasounds, there were no differences in crown rump lengths or nuchal translucencies between the groups. Likewise, in 195-second trimester ultrasounds, no differences were noted in biometry. Second trimester umbilical artery systolic to diastolic ratios were higher in marijuana users compared to nonusers (4.02 versus 3.92, p = .024). In the third trimester, 26 of 192 marijuana exposed fetuses were growth restricted compared to 6 of 192 controls (p = .002), and umbilical artery systolic to diastolic ratios were higher (3.52 versus 3.12, p = .0001). Four cases of absent and reversed end diastolic flow were observed in marijuana users, while no cases were observed in controls. CONCLUSIONS: Our data shows that daily marijuana use is associated with impaired fetal growth and increased placental vascular resistance. Marijuana consumption in pregnancy should be avoided until further studies delineate its exact potential for fetotoxicity.

Associations of Dietary Bioactive Compounds with Maternal Adiposity and Inflammation in Gestational Diabetes: An Update on Observational and Clinical Studies.

Gestational diabetes mellitus (GDM) is a common complication of pregnancy that adversely affects maternal and offspring health. Maternal obesity, oxidative stress, and inflammation have been implicated in GDM. In non-pregnant adults, intakes of dietary bioactive compounds inversely associate with insulin resistance and inflammation. However, associations of dietary bioactive compounds with biomarkers of adiposity, antioxidant vitamin and mineral status, oxidative stress, and inflammation in GDM have not been fully elucidated. We addressed this gap by conducting a semi-quantitative review of observational studies and randomized controlled trials published between 2010 and 2020 and retrieved from Google Scholar, Medline, and PubMed. Our analysis revealed that women with GDM are more likely to consume a pro-inflammatory diet before pregnancy and tend to consume fewer antioxidant vitamins and minerals during pregnancy than healthy pregnant women. Women with GDM also have lower blood levels of vitamins A, C, and D and certain adipokines. Several dietary bioactive compounds were noted to improve antioxidant status and biomarkers of inflammation. The Dietary Approaches to Stop Hypertension (DASH) diet and soybean oligosaccharides increased antioxidant enzyme levels. Supplementing n-3 fatty acids, probiotics, synbiotics, and trace elements increased antioxidant enzymes and reduced hs-CRP and MDA. Improvements in inflammation by vitamin D may be contingent upon co-supplementation with other dietary bioactive compounds.

Whole blood in the management of hypovolemia due to obstetric hemorrhage.

OBJECTIVE: To study the use of blood products including whole blood, for the management of obstetric hemorrhage requiring transfusion. METHODS: This was a population-based, observational study of all women receiving blood for hypovolemia because of hemorrhage at the Parkland obstetrics service between March 24, 2002, and June 12, 2006. Hypovolemia was diagnosed in women who sustained hemorrhages sufficient enough to provoke hemodynamic instability. RESULTS: A total of 66,369 women gave birth during the study period, and 1,540 (2.3%) received a blood transfusion. Six hundred fifty-nine (43%) received only whole blood, 593 (39%) received only packed red blood cells, and 288 (19%) received combinations of blood products, including thawed plasma, platelets, and cryoprecipitate. The number of units transfused was similar in the whole blood and packed red blood cell groups (mean 2 units) and higher in the combination group (mean 5.5 units). Complications attributable to hypovolemia were similar in frequency in the whole blood and packed red blood cells groups, including intensive care unit admission (1%), hypofibrinogenemia (0.3%), and adult respiratory syndrome (0.5% compared with .3%). Acute tubular necrosis was more common in the packed red blood cell group (2% compared with 0.3%, P<.001). All of these outcomes were increased in the combination transfusion group. There were three maternal deaths in the cohort, two in the combination group and one in the packed red blood cells group. CONCLUSION: The risk of acute tubular necrosis is significantly reduced in women receiving whole blood transfusion for hypovolemia due to obstetric hemorrhage. LEVEL OF EVIDENCE: III.

Cesarean delivery for the second twin.

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

Comparison of fetal biometric values with sonographic and 3D reconstruction MRI in term gestations.

OBJECTIVE: We sought to compare the fetal biometric values head and abdominal circumferences, biparietal and occipital-frontal diameters, and left and right ventricular atrial diameters obtained with contemporaneous sonography and 3D MRI reconstructions in term pregnancies. SUBJECTS AND METHODS: A total of 107 nulliparous women evaluated as having uncomplicated pregnancies and scheduled for induction at 42 completed weeks gave their informed consent and underwent MRI and sonography within 3 hours of each other. Two single-shot fast spin-echo MRI sequences were performed with 7- and 4-mm slice thicknesses and no gap. A single observer performed MRI postprocessing to obtain biometric values. A single sonographer using a 3- to 5-MHz curvilinear transducer performed transabdominal sonography. Concordance correlation and Bland-Altman analysis of differences were performed. RESULTS: Concordance correlation was poor for both right (0.024) and left (0.005) ventricular atrial diameters. There were moderate concordance correlations for head (0.56) and abdominal (0.53) circumferences and biparietal diameter (0.61). Occipital-frontal diameter had fair correlation (0.27). CONCLUSION: Comparison between contemporaneous sonographic and 3D reconstructed MR images at late gestational ages shows acceptable correlation between the two techniques for head circumference, abdominal circumference, and biparietal diameter.